7.5 Sample Documentation

Open Resources for Nursing (Open RN)

Sample Documentation of Expected Findings

The patient’s skin tone is appropriate for ethnicity and they are not diaphoretic. Facial movements are symmetrical. Nares are patent and no drainage is present. Uvula and tongue are midline. Teeth and gums are in good condition. Patient is able to swallow without difficulty. Trachea is midline. There is no enlargement of the lymph nodes.

Sample Documentation of Unexpected Findings

The patient has a history of asthma and uses a fluticasone inhaler daily. White patches are present on the tongue and inner buccal membranes. Dr. Smith was notified at 1530 and a new order for nystatin medication was received and administered. Patient was instructed to rinse their mouth after every use of fluticasone to prevent thrush from recurring.


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Nursing Skills by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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